Pharmacology - Toxicities and Side Effects

Question 1

Specific antidotes/treatments for these toxins

• Acetaminophen
• AChE inhibitors, organophosphates
• Amphetamines (basic)
• Antimuscarinic, anticholinergic agents
• Benzodiazepines
• β-blockers
• Carbon monoxide
• Copper, arsenic, gold
• Cyanide
• Digitalis

Answer 1

• Acetaminophen
  
  • N-acetylcysteine (replenishes glutathione)
• AChE inhibitors, organophosphates
  
  • Atropine followed by pralidoxime
• Amphetamines (basic)
  
  • NH4Cl (acidify urine)
• Antimuscarinic, anticholinergic agents
  
  • Physostigmine salicylate, control hyperthermia
• Benzodiazepines
  
  • Flumazenil
• β-blockers
  
  • Glucagon
• Carbon monoxide
  
  • 100% O2, hyperbaric O2
• Copper, arsenic, gold
  
  • Penicillamine
• Cyanide
  
  • Nitrite + thiosulfate, hydroxocobalamin
• Digitalis
  
  • Anti-dig Fab fragments

Question 2

Specific antidotes/treatments for these toxins

• Heparin
• Iron
• Lead
• Mercury, arsenic, gold
• Methanol, ethylene glycol (antifreeze)
• Methemoglobin
• Opioids
• Salicylates
• TCAs
• tPA, streptokinase, urokinase
• Warfarin

Answer 2

• Heparin
  
  • Protamine sulfate
• Iron
  
  • Deferoxamine, deferasirox
• Lead
  
  • EDTA, dimercaprol, succimer, penicillamine
• Mercury, arsenic, gold
  
  • Dimercaprol (BAL), succimer
• Methanol, ethylene glycol (antifreeze)
  
  • Fomepizole > ethanol, dialysis
• Methemoglobin
  
  • Methylene blue, vitamin C
• Opioids
  
  • Naloxone
• Salicylates
  
  • NaHCO3 (alkalinize urine), dialysis
• TCAs
  
  • NaHCO3 (plasma alkalinization)
• tPA, streptokinase, urokinase
  
  • Aminocaproic acid
• Warfarin
  
  • Vitamin K, plasma (if active bleeding)

Question 3

Causal agents of drug reactions—cardiovascular

• Coronary vasospasm
• Cutaneous flushing
• Dilated cardiomyopathy
• Torsades de pointes

Answer 3

• Coronary vasospasm
  
  • Cocaine, sumatriptan, ergot alkaloids
• Cutaneous flushing
  
  • VANC: Vancomycin, Adenosine, Niacin, Ca2+ channel blockers
• Dilated cardiomyopathy
  
  • Doxorubicin, daunorubicin
• Torsades de pointes
  
  • Kill The CHAMPio_N_: ​K channel blockers (class III, e.g. sotalol), TCAs, Chloroquine, Haloperidol, Antipsychotics, Macrolides, Protease inhibitors, Na channel blockers (class IA, e.g. quinidine)

Question 4

Causal agents of drug reactions—endocrine/reproductive

• Adrenocortical insufficiency
• Hot flashes
• Hyperglycemia
• Hypothyroidism

Answer 4

• Adrenocortical insufficiency
  
  • HPA suppression 2° to glucocorticoid withdrawal
• Hot flashes
  
  • Tamoxifen, clomiphene
• Hyperglycemia
  
  • Taking Pills Necessitates Having Blood Checked
  • Tacrolimus, Protease inhibitors, Niacin, HCTZ, β-blockers, Corticosteroids
• Hypothyroidism
  
  • Lithium, amiodarone, sulfonamides

Question 5

Causal agents of drug reactions—GI

• Acute cholestatic hepatitis, jaundice
• Diarrhea
• Focal to massive hepatic necrosis
• Hepatitis
• Pancreatitis
• Pseudomembranous colitis

Answer 5

• Acute cholestatic hepatitis, jaundice
  
  • Erythromycin
• Diarrhea
  
  • Might Excite Colon On Accident
  • Metformin, Erythromycin, Colchicine, Orlistat, Acarbose
• Focal to massive hepatic necrosis
  
  • Liver “HAVAc”
  • Halothane, Amanita phalloides (death cap mushroom), Valproic acid, Acetaminophen
• Hepatitis
  
  • INH
• Pancreatitis
  
  • Drugs Causing A Violent Abdominal Distress
  • Didanosine, Corticosteroids, Alcohol, Valproic acid, Azathioprine, Diuretics (furosemide, HCTZ)
• Pseudomembranous colitis
  
  • Clindamycin, ampicillin, cephalosporins
  • Antibiotics predispose to superinfection by resistant C. difficile

Question 6

Causal agents of drug reactions—hematologic

• Agranulocytosis
• Aplastic anemia
• Direct Coombs-positive hemolytic anemia
• Gray baby syndrome
• Hemolysis in G6PD deficiency
• Megaloblastic anemia
• Thrombocytopenia
• Thrombotic complications

Answer 6

• Agranulocytosis
  
  • Drugs CCCrush Myeloblasts and Promyelocytes
  • Dapsone, Clozapine, Carbamazepine, Colchicine, Methimazole, Propylthiouracil
• Aplastic anemia
  
  • Can’t Make New Blood Cells Properly
  • Carbamazepine, Methimazole, NSAIDs, Benzene, Chloramphenicol, Propylthiouracil
• Direct Coombs-positive hemolytic anemia
  
  • Methyldopa, penicillin
• Gray baby syndrome
  
  • Chloramphenicol
• Hemolysis in G6PD deficiency
  
  • Hemolysis IS D PAIN
  • INH, Sulfonamides, Dapsone, Primaquine, Aspirin, Ibuprofen, Nitrofurantoin
• Megaloblastic anemia
  
  • Having a blast with PMS
  • Phenytoin, Methotrexate, Sulfa drugs
• Thrombocytopenia
  
  • Heparin, cimetidine
• Thrombotic complications
  
  • OCPs (e.g., estrogens)

Question 7

Causal agents of drug reactions—musculoskeletal/skin/connective tissue

• Fat redistribution
• Gingival hyperplasia
• Hyperuricemia (gout)
• Myopathy
• Osteoporosis
• Photosensitivity
• Rash (Stevens-Johnson syndrome)
• SLE-like syndrome
• Teeth discoloration
• Tendonitis, tendon rupture, and cartilage damage

Answer 7

• Fat redistribution
  
  • Fat** **PiG
  • Protease inhibitors, Glucocorticoids
• Gingival hyperplasia
  
  • Phenytoin, verapamil, cyclosporine, nifedipine
• Hyperuricemia (gout)
  
  • Painful Tophi and Feet Need Care
  • Pyrazinamide, Thiazides, Furosemide, Niacin, Cyclosporine
• Myopathy
  
  • Fibrates, niacin, colchicine, hydroxychloroquine, interferon-α, penicillamine, statins, glucocorticoids
• Osteoporosis
  
  • Corticosteroids, heparin
• Photosensitivity
  
  • SAT For Photo
  • Sulfonamides, Amiodarone, Tetracyclines, 5-FU
• Rash (Stevens-Johnson syndrome)
  
  • CLAPPPERS
  • Carbamazepine, _L_amotrigine, _A_llopurinol, _P_henytoin, _P_henobarbital, _P_enicillin, _Ethosuximide, (R_ash), _S_ulfa drugs
• SLE-like syndrome
  
  • SHIPP-E
  • Sulfa drugs, Hydralazine, INH, Procainamide, Phenytoin, Etanercept
• Teeth discoloration
  
  • Tetracyclines
• Tendonitis, tendon rupture, and cartilage damage
  
  • Fluoroquinolones

Question 8

Causal agents of drug reactions—neurologic

• Cinchonism
• Parkinson-like syndrome
• Seizures
• Tardive dyskinesia

Answer 8

• Cinchonism
  
  • Quinidine, quinine
• Parkinson-like syndrome
  
  • Cogwheel rigidity of ARM
  • Antipsychotics, Reserpine, Metoclopramide
• Seizures
  
  • With seizures, I BITE My tongue
  • ​INH (vitamin B6 deficiency), Bupropion, Imipenem/cilastatin, Tramadol, Enflurane, Metoclopramide
• Tardive dyskinesia
  
  • Antipsychotics, metoclopramide

Question 9

Causal agents of drug reactions—renal/genitourinary

• Diabetes insipidus
• Fanconi syndrome
• Hemorrhagic cystitis
• Interstitial nephritis
• SIADH

Answer 9

• Diabetes insipidus
  
  • Lithium, demeclocycline
• Fanconi syndrome
  
  • Expired tetracycline
• Hemorrhagic cystitis
  
  • Cyclophosphamide, ifosfamide
  • Prevent by coadministering with mesna
• Interstitial nephritis
  
  • Methicillin, NSAIDs, furosemide
• SIADH
  
  • Can’t Concentrate Serum Sodium
  • Carbamazepine, Cyclophosphamide, SSRIs

Question 10

Causal agents of drug reactions—respiratory

• Dry cough
• Pulmonary fibrosis

Answer 10

• Dry cough
  
  • ACE inhibitors
• Pulmonary fibrosis
  
  • Breathing Air Badly from Medications
  • Bleomycin, Amiodarone, Busulfan, Methotrexate

Question 11

Causal agents of drug reactions—multiorgan

• Antimuscarinic
• Disulfiram-like reaction
• Nephrotoxicity/ototoxicity

Answer 11

• Antimuscarinic
  
  • muscles wear A HAT
  • Atropine, H1-blockers, Antipsychotics, TCAs
• Disulfiram-like reaction
  
  • Must Stop Getting Pina Coladas
  • Metronidazole, 1st-generation _S_ulfonylureas, _G_riseofulvin, _P_rocarbazine, certain _C_ephalosporins
• Nephrotoxicity/ototoxicity
  
  • Aminoglycosides, vancomycin, loop diuretics, cisplatin

Question 12

Cytochrome P-450 interactions (selected):
Inducers (+) (9)

Answer 12

• My New Guiness, Coronas, & PBRS induce CHRONIC ALCOHOLISM“
• Modafinil
• Nevirapine
• Griseofulvin
• Carbamazepine
• Phenytoin
• Barbiturates (e.g. phenobarbital)
• Rifampin
• St. John’s wort
• Chronic alcohol use

Question 13

Cytochrome P-450 interactions (selected):
Substrates (8)

Answer 13

• Always, Always, Always, Always Think When Starting Others
• Anti-epileptics
• Antidepressants
• Antipsychotics
• Anesthetics
• Theophylline
• Warfarin
• Statins
• OCPs

Question 14

Cytochrome P-450 interactions (selected):
Inhibitors (-) (12)

Answer 14

• Q CRACK AMIGGOS
• Quinidine
• Cimetidine
• Ritonavir (protease inhibitors)
• Acute alcohol abuse
• Ciprofloxacin
• Ketoconazole
• Amiodarone
• Macrolides
• Isoniazid
• Grapefruit juice
• Gemfibrozil
• Omeprazole
• Sulfonamides

Question 15

Sulfa drugs

• Examples
• Patients with sulfa allergies may develop/

Answer 15

• Popular Sulfa FACTSS
  
  • Probenecid, Sulfonamide antibiotics, Furosemide, Acetazolamide, Celecoxib, Thiazides, Sulfasalazine, Sulfonylureas.
• Patients with sulfa allergies may develop fever, urinary tract infection, Stevens-Johnson syndrome, hemolytic anemia, thrombocytopenia, agranulocytosis, and urticaria (hives).
• Symptoms range from mild to life threatening.